472 Septic Application Permit & Compliance 2005 No Inn-Sc
FORM 1-APPLICATION FOR DSCP /�
Fee a. 6"C7 lea
Commonwealth of Massachusetts
NORTHAMPTON, Massachusetts
Application for Disposal System Construction Permit
Application is hereby made for a Permit to Construct 0 or Repair(X) an On-site Sewage Disposal
system at:
Location Address or Lot No. Owner's Name,Address and Tel.#
472 COLES MEADOW ROAD JOHN MCCOY
Installer's Name,Address,and Tel. #
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder NO
Other Type of Building No.of Persons Showers Cafeteria
Other Fixtures
472 COLES MEADOW ROAD
NORTHAMPTON MA 01060
5'd b — 1977
Designer's Name,Address and Tel.it
MacLeay Associates, Inc.
102 Bridge Street �/ 2L
Shelburne Falls,MA 01370
(413) 625-9774 ff 9-1757
Vic` (.113i 1711-6499 '.43q
Design Flow 330 gallons per day. Calculated daily flow 336 gallons
Plan Date 08/04/1997 Number of Sheets ONE Revision Date 6/15/05
Title SUBSURFACE SEWAGE DISPOSAL PLAN IN NORTHAMPTON,MASS FOR
JOHN MCCOY,472 COLES MEADOW ROAD.
Description of Soil SANDY LOAM SEE PLAN FOR DETAILED TEST PIT DESCRIPTIONS,
SEASONAL HIGH GROUNDWATER AT 16"PERC RATE 15 MIN./INCH. .WITNESSED BY
PETER McERLAIN
Nature of Repairs or Alterations(Answer when applicable)INSTALL SEPTIC TANK,D-BOX AND
LEACH TRENCHES
Date last inspected:
-*Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to
place the system in operation until . -- ificate of Compliance has been issued by this Board of Health.
Dat4//5 /'2 y./
Application Approved by
Signed
A
Date ltd/tl/K?
Application Disapproved for the following reasons
Permit No. ZGDS— ( Date Issued
[e 4tt(or
FORM 2-DISPOSAL SYSTEM CONSTRUCTION PERMIT
Commonwealth of Massachusetts
NORTHAMPTON, Massachusetts
Disposal System Construction Permit
No. Zoos- 39
Permission is hereby granted to JOHN MCCOY to construct 0 or repair(X) an On-
site Sewage System located at
472 COLES MEADOW ROAD
and as described in the above Application for Disposal System Construction Permit. The
applicant recognizes his/her duty to comply with Title 5 and the following local provisions
or special conditions.
All construction must be completed within two years of the date below.
Date o ticaJ /7, 2-oio
Approved by
/NUT I. Mu• 1tU. Kt, M.B., 680.
DECOR of HEALTH
FORM 3-CERTIFICATE OF COMPLIANCE
Commonwealth of Massachusetts
NORTHAMPTON, Massachusetts
Certificate of Compliance
This is to Certify, that the On-site Sewage Disposal System installed 0
or repaired/replaced(X) on by
for JOHN MCCOY at
472 COLES MEADOW ROAD
has been constructed in accordance with the provisions of Title 5 and the for
Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance
with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that
the system will function as designed. The Certificate expires on
Date Inspector
•
Septic System Permit Payment Receipt
Permit*%t6.3?Date: G} Z Const Repair/
Amount: Cco.n Cash Check# 27pp01
Address: tin f 9L mataoCI
Owner: 9t%n.t me
JOHN M. McCOY, JR.
472 COLES MEADOW RD.
NORTHAMPTON. MA 01060
5-19/110
6078091191
rnrTo➢i6 ._.-./y D/ /O/,r/i. % $
ORD!R OF
DOLLARS B
2901
Fleet
43
"4c. .
S .
L 1000 L381: 00 768 5 L 7 8 1 0 2 9 0 /